Anaemia and the Gynae-Oncology Patient
Mrs Taylor continued…
Predictably the blood results will not be available for more than an hour, so you decide to run a blood gas on Mrs Taylor to check her haemoglobin quickly. It comes back as 72g/L. The surgical operation note confirms that Mrs Taylor lost 1.3 litres of blood in theatre, that was missed during handover and interestingly you note that Mrs Taylor was anaemic before surgery also.
The World Health Organisation defines perioperative anaemia as a haemoglobin (Hb) <130g/L for males and <120g/L for females.
Pre-operative anaemia is often poorly managed pre-operatively with up to 60% of patients being anaemic prior to surgery. There are many reasons for this, for example, iron-deficiency, chronic disease or inflammation, chronic blood loss, or a combination. Iron deficiency, either due to poor absorption or utilisation, is by far the most common cause of anaemia in patients undergoing surgery. It is particularly common for female patients to be iron deficient, and this compounded by the effects of their malignancy means that it is important to have high index of suspicion for anaemia in gynae-oncology patients.
What can we do?
Historically, we have treated severe anaemia or blood loss in the perioperative period with giving blood products. However, we know that this comes with its own risks, how many Serious Hazards Of Transfusion (SHOT) can you name?
Blood is an expensive product (£140/unit on average in the UK). Blood is also a precious resource within the NHS and therefore, we try to follow the pillars of ‘Patient Blood Management’ (PBM).
The Patient Blood Management guide (2016) for clinicians whose patients are at risk for anaemia, coagulation disorders, or severe blood loss.
It sets a three-pillar strategy for the application of PBM and gives an overview of research in PBM including landmark studies and current clinical trials.
Patient Blood Management book. (Image source)
Patient Blood Management (PBM)
The concept of PBM is to avoid unnecessary allogenic blood transfusion to reduce perioperative complications and improve patient safety. The triad of PBM includes early detection and correction of preoperative anaemia, minimising perioperative blood loss and restrictive transfusion practice.
Establishing PBM in perioperative pathways has many advantages including optimisation of patients, reducing patient exposure to risk and resource conservation of allogenic blood. The use of IV iron both before and after surgery plays a role in PBM but requires multi-disciplinary engagement and coordination.
It is important to address the cause of the anaemia – for example the iron deficiency with either oral or intravenous replacement prior to surgery. However, patients often slip through the net, and this does not get picked up until after their operation as exemplified here with Mrs Taylor.
Many hospital trusts run iron transfusion clinics prior to surgery, in an attempt to reduce the incidence of anaemia, optimise haemoglobin and reduce the amount of blood and blood products a patient may need in the perioperative period. The outcome data from trial remains mixed, but it is clear the identification and diagnosis of the cause of anaemia before surgery is important.
Centre for Perioperative Care (CPOC) published guidance in addressing perioperative anaemia by producing a guideline for the Management of Anaemia in the Perioperative Pathway. It provides guidance and a framework for local service development.
We encourage you look at this document.
The three pillars of PBM. (Image source)
Mrs Taylor
An elderly woman patient in bed in an NHS hospital ward. (Alamy image, source and credit: Kathy Dewitt)
Here we go back to the bloods you sent to the lab on POCU admission. It is likely you requested a full blood count to check the haemoglobin and a urea and electrolytes to check an early renal function.
You might also have checked there was an in-date group and cross match sample and even some blood available, because now you are likely to need it!
The gynaecology registrar reviews the patient and is happy that the bleeding has stopped. He explains that the patient has had a difficult hysterectomy which has likely caused a lot of the observed blood loss.
As Mrs Taylor’s haemoglobin level requires a blood transfusion, it is decided to transfuse 2 units of packed red cells to run over 4 hours.
Unit of red blood cells being transfused to a patient. (Photo credit: Louise Allen Photography)
Major blood loss in abdominal-pelvic surgery is not uncommon and is associated with worse patient outcomes. When admitting a patient with gynaecological malignancy, like so many other malignancies one should confirm the absence of anaemia before surgery, the estimated blood loss during surgery and the threshold (or targets for Hb) and blood administration. Always have your post surgical drains visible, initially measured hourly while at the same time reviewing wounds for blood loss, which should include “hidden-losses” e.g., vaginal bleeding.
When sending routine post-operative bloods, get into the habit of confirming a lab sample for cross-match is in date – you never know when you will need it.
While we talk about the need for immediate blood transfusion locate your units emergency blood fridge, know the drill for collecting blood and, of course, checking it. Hospital trusts ensure staff remain up to date by mandating compulsory annual blood product training. Nowhere greater than in POCU is this drill so important.
Mrs Taylor was never in immediate danger but could have been exposed to a life threatening haemorrhage.
The role of postoperative intravenous Iron?
Up to 90% of patients who have undergone major surgery may be anaemic postoperatively. The causes are multifactorial, and may include untreated preoperative anaemia, perioperative blood loss, haemodilution, and ineffective erythropoiesis secondary to inflammation.
All patients with preoperative anaemia, who have undergone major surgery (defined as blood loss >500ml or lasting >2hrs) should have a full blood count checked and cause of anaemia investigated.
As stated, it is important to be vigilant when checking for blood loss postoperatively – especially from places not obviously on show. Gynaecology patients can have significant postoperative vaginal bleeding and their pads should be check and changed regularly and blood loss recorded. If you are concerned that the blood loss is heavier than expected, this should be raised with the anaesthetist or surgical team for review.
Significant blood losses requires mandatory increased frequency of vital signs observations – as you have learned already, often its not the absolute numbers that concern us, but the trend over time – a bleeding/anaemic patient should be reviewed regularly by the whole team and a plan identified and agreed. Ongoing blood loss in a postoperative patient should be treated as a surgical emergency.
The role of intravenous replacement of iron is often considered in patients who are iron deficient preoperatively as per recommended frameworks e.g. CPOC perioperative anaemia pathway.
There does seem to be a role for IV iron in postoperative patients as oral iron is limited by its poor absorption and frequent intolerance. But the evidence of when and to who we give postoperative iron transfusion is limited; and the association with important safety outcomes, such as infection remains uncertain.
Road to Recovery: Mastering Postoperative Care of the High-Risk Patient
Road to Recovery: Mastering Postoperative Care of the High-Risk Patient
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